EDAPT: NCLEX Readiness: Basic Care and Comfort
The nurse is caring for a client who has had a left-sided ischemic stroke and is having difficulty
with expressive aphasia. Which interventions would be most appropriate to assist the client
with communication? Select all that apply. - correct answer ▸ Offer the client a white board for
communication.
▸ Decrease the amount of environmental noise.
▸ Give the client time to respond.
The nurse is caring for a client who has been diagnosed with metastatic brain cancer and is
moving to hospice care. For each potential prescription, click to specify if the prescription is
anticipated, nonessential, or contraindicated for the care of the client. - correct answer
*Anticipated:*
▸ Apply fentanyl patch 50 mcg every 72 hours.
▸ Treat with hydromorphone 7.5 mg oral (po) around the clock.
*Nonessential:*
▸ Educate the client and family about narcotic addiction.
*Contraindicated:*
▸ Treat with curative radiation to head and neck once a week.
▸ Hold hydromorphone for RR <10.
The nurse is providing postmortem care to a client whose death was anticipated. Priority
nursing actions include __________ and __________. - correct answer ▸ Replacing dentures
▸ Placing arms at the sides
Sleep disturbances can have detrimental health effects on clients with medical conditions.
Match the consequence of sleep disturbance to each client scenario. Each consequence may
relate to more than one scenario. - correct answer *Client With a Stage III Pressure Ulcer:*
▸ Decreased tissue renewal
▸ Increased stress response
*Client With Alzheimer's Disease:*
,▸ Decreased ability to concentrate
▸ Increased confusion and irritability
*Client With Fall Risk:*
▸ Decreased reflexes
▸ Decreased ability to concentrate
▸ Decreased visual acuity
The nurse is caring for a client with impacted cerumen in the right ear. The healthcare provider
writes a prescription to irrigate the ear. Please the nursing actions for this procedure in the
correct order. - correct answer 1. Place the client in the sitting position.
2. Place the emesis basin under the ear.
3. Pull the auricle up and back.
4. Direct the solution above the impaction.
5. Use mild lubricant drops to soften the wax.
For each nonpharmacologic pain relief action, indicate if the action is appropriate or
contraindicated for a client with rheumatoid arthritis (RA). - correct answer *Appropriate:*
▸ Offer moist heat.
▸ Offer guided imagery teaching.
▸ Refer the client for acupuncture.
*Contraindicated:*
▸ Offer a rigorous exercise program.
▸ Assist the client to flex the legs and arms.
When planning care for several clients, which client should receive hygiene measures first? -
correct answer An older adult with diabetes who was incontinent of urine and stool
The nurse must understand sleep across the lifespan. Match the client's age to the correct sleep
characteristic. - correct answer *2-year-old* - May have separation anxiety.
*Neonate* - Displays high percentage of rapid eye movement (REM) sleep.
,*10-year-old* - May resist sleeping to show independence.
*70-year-old* - Has shorter episodes of deep sleep.
*4-year-old* - Bedtime fears and bed-wetting may occur.
*16-year-old* - Likely to have an electronic device on at bedtime.
*50-year-old* - Insomnia may be common.
The nurse is caring for a client who was admitted to the hospital after falling at home. The
client is unable to ambulate, and their left leg is shortened and externally rotated. The nurse
notes ecchymosis on the left lateral hip. The client is placed in skin traction.
For each potential nursing action, indicate whether the action is indicated, nonessential, or
contraindicated. - correct answer *Indicated:*
▸ Inspect the skin every two hours.
▸ Incentive spirometry every two hours.
*Nonessential:*
▸ Assess vital signs every hour.
▸ Monitor blood glucose every two hours.
*Contraindicated:*
▸ Place the traction weights on the bed.
▸ Assess neurovascular status every day.
While ambulating with crutches, the client moves injured side's crutch forward with the injured
leg and then moves the non-injured crutch at the same time as the injured leg. The nurse will
document that the client is using a __________ gait while ambulating.
, While ambulating with crutches, the client moves both crutches forward and then moves both
legs forward to the same point as the crutches. The nurse will document that the client is using
a __________ gait while ambulating.
When educating on the use of a cane going up the stairs, the nurse will instruct the client to
move the __________ leg up first. - correct answer ▸ 2-point
▸ Swing-to
▸ Strong
Select to highlight the areas that are concerning to the nurse. Click to apply. - correct answer ▸
7/10 sharp pain
▸ Facial grimacing
▸ Diaphoretic
Identify the additional assessments the nurse should complete for this client during the
admissions assessment. Select the five (5) that apply. - correct answer ▸ Size of indwelling
urinary catheter
▸ Urine output and color
▸ Pain assessment after repositioning
▸ Bowel sounds
▸ Pedal pulses
Identify the staging of the pressure injury, 2 supporting findings, and 2 management strategies.
Select the correct answer s in the boxes provided. - correct answer *Findings:*
▸ Sacral pain
▸ Open, shallow wound
*Staging:*
▸ Stage 2
*Management Strategies:*
The nurse is caring for a client who has had a left-sided ischemic stroke and is having difficulty
with expressive aphasia. Which interventions would be most appropriate to assist the client
with communication? Select all that apply. - correct answer ▸ Offer the client a white board for
communication.
▸ Decrease the amount of environmental noise.
▸ Give the client time to respond.
The nurse is caring for a client who has been diagnosed with metastatic brain cancer and is
moving to hospice care. For each potential prescription, click to specify if the prescription is
anticipated, nonessential, or contraindicated for the care of the client. - correct answer
*Anticipated:*
▸ Apply fentanyl patch 50 mcg every 72 hours.
▸ Treat with hydromorphone 7.5 mg oral (po) around the clock.
*Nonessential:*
▸ Educate the client and family about narcotic addiction.
*Contraindicated:*
▸ Treat with curative radiation to head and neck once a week.
▸ Hold hydromorphone for RR <10.
The nurse is providing postmortem care to a client whose death was anticipated. Priority
nursing actions include __________ and __________. - correct answer ▸ Replacing dentures
▸ Placing arms at the sides
Sleep disturbances can have detrimental health effects on clients with medical conditions.
Match the consequence of sleep disturbance to each client scenario. Each consequence may
relate to more than one scenario. - correct answer *Client With a Stage III Pressure Ulcer:*
▸ Decreased tissue renewal
▸ Increased stress response
*Client With Alzheimer's Disease:*
,▸ Decreased ability to concentrate
▸ Increased confusion and irritability
*Client With Fall Risk:*
▸ Decreased reflexes
▸ Decreased ability to concentrate
▸ Decreased visual acuity
The nurse is caring for a client with impacted cerumen in the right ear. The healthcare provider
writes a prescription to irrigate the ear. Please the nursing actions for this procedure in the
correct order. - correct answer 1. Place the client in the sitting position.
2. Place the emesis basin under the ear.
3. Pull the auricle up and back.
4. Direct the solution above the impaction.
5. Use mild lubricant drops to soften the wax.
For each nonpharmacologic pain relief action, indicate if the action is appropriate or
contraindicated for a client with rheumatoid arthritis (RA). - correct answer *Appropriate:*
▸ Offer moist heat.
▸ Offer guided imagery teaching.
▸ Refer the client for acupuncture.
*Contraindicated:*
▸ Offer a rigorous exercise program.
▸ Assist the client to flex the legs and arms.
When planning care for several clients, which client should receive hygiene measures first? -
correct answer An older adult with diabetes who was incontinent of urine and stool
The nurse must understand sleep across the lifespan. Match the client's age to the correct sleep
characteristic. - correct answer *2-year-old* - May have separation anxiety.
*Neonate* - Displays high percentage of rapid eye movement (REM) sleep.
,*10-year-old* - May resist sleeping to show independence.
*70-year-old* - Has shorter episodes of deep sleep.
*4-year-old* - Bedtime fears and bed-wetting may occur.
*16-year-old* - Likely to have an electronic device on at bedtime.
*50-year-old* - Insomnia may be common.
The nurse is caring for a client who was admitted to the hospital after falling at home. The
client is unable to ambulate, and their left leg is shortened and externally rotated. The nurse
notes ecchymosis on the left lateral hip. The client is placed in skin traction.
For each potential nursing action, indicate whether the action is indicated, nonessential, or
contraindicated. - correct answer *Indicated:*
▸ Inspect the skin every two hours.
▸ Incentive spirometry every two hours.
*Nonessential:*
▸ Assess vital signs every hour.
▸ Monitor blood glucose every two hours.
*Contraindicated:*
▸ Place the traction weights on the bed.
▸ Assess neurovascular status every day.
While ambulating with crutches, the client moves injured side's crutch forward with the injured
leg and then moves the non-injured crutch at the same time as the injured leg. The nurse will
document that the client is using a __________ gait while ambulating.
, While ambulating with crutches, the client moves both crutches forward and then moves both
legs forward to the same point as the crutches. The nurse will document that the client is using
a __________ gait while ambulating.
When educating on the use of a cane going up the stairs, the nurse will instruct the client to
move the __________ leg up first. - correct answer ▸ 2-point
▸ Swing-to
▸ Strong
Select to highlight the areas that are concerning to the nurse. Click to apply. - correct answer ▸
7/10 sharp pain
▸ Facial grimacing
▸ Diaphoretic
Identify the additional assessments the nurse should complete for this client during the
admissions assessment. Select the five (5) that apply. - correct answer ▸ Size of indwelling
urinary catheter
▸ Urine output and color
▸ Pain assessment after repositioning
▸ Bowel sounds
▸ Pedal pulses
Identify the staging of the pressure injury, 2 supporting findings, and 2 management strategies.
Select the correct answer s in the boxes provided. - correct answer *Findings:*
▸ Sacral pain
▸ Open, shallow wound
*Staging:*
▸ Stage 2
*Management Strategies:*
